Can We Keep Kids Safe at School?

No doubt, most of us have been inundated with questions from parents about whether their children should return to school in person. A large national survey of parents of children aged 5-17 years found that families were split over what they planned to do. Fear of COVID-19 in general as well as specific fear of multisystem inflammatory disease were both associated with an intention to keep children at home.

News reports of rising numbers of infected children have probably helped fuel parental concerns. Fortunately, the evidence suggests that severe illness in children is the exception and not the rule.

Parental concerns over whether to send children to school suggests an obvious role for pediatric clinicians. Discussing these concerns can reassure families and move us further toward the American Academy of Pediatrics' (AAP) goal of returning more kids to in-person learning.

But should we be doing that? What is the evidence that it can be done safely?

Kids and COVID-19: Quick Review of Evidence

How many children reporting to school are likely to be positive in the first place? A recent study looked at 30,000 asymptomatic children who underwent preoperative evaluations at a US children's hospital, finding a positivity rate of less than 1%. The only factor related to the prevalence was the respective community's infection rate at the time the child was evaluated. Other potential factors, such as rural or urban location, the number of tests done, the region, or site of sample collection were all unrelated to SARS-CoV-2 prevalence.

This study illustrates several points. First, driving down community rates benefits children in that needed surgical procedures (and, presumably, other medical care) can resume. Second, these data were from around the United States during a snapshot of time between May and July. The prevalence of acute infection among these presurgical children was low then. By contrast, studies of antibody positivity rates from samples taken around the same time demonstrated community antibody positivity rates generally < 10%, reaching only 13.7% among healthcare workers in New York (presumably individuals with some of the highest potential exposure), collected during the same time period. More recent data will continue to be published, but as of summer 2020, these studies suggest that we were nowhere near the antibody prevalence rate that would indicate herd immunity.

Do kids transmit the virus? Despite the high viral loads in the upper respiratory tracts of children, other data from early in the pandemic seemed to indicate that children with SARS-CoV-2 rarely transmit the virus to close personal contacts in the home. In a short report detailing household clusters of SARS-CoV-2 in Switzerland, only 3 of 39 children (8%) were the first in their respective households to have the virus.

But that is countered by a new report from Utah, published in a recent MMWR. That analysis utilized contact tracing data to retrospectively construct transmission chains. The investigators documented 12 daycare children who did transmit virus, including an 8-month-old who apparently infected both parents. The conclusion from the CDC was that "transmission likely occurred from children with confirmed COVID-19 in a child care facility to 25% of their nonfacility contacts," including parents, siblings, and other adults.

The most likely scenario is that children almost certainly can transmit the virus, and that they may be less likely to do so than adults, but this is an area of evolving data and information. 

Should kids who are positive be quarantined? Some data from South Korea collected early in the pandemic indirectly support the idea of a 10- to 14-day isolation period for infected children. Researchers followed 91 children with COVID-19 confirmed by laboratory testing, looking for clinical symptoms as well as viral detection. The children had been tested for a range of reasons, including nonspecific symptoms, contact with a person with confirmed infection, travel to an endemic area, or community surveillance.

Almost one quarter of the children (22%) had no symptoms throughout the entire 2-week study period. Fewer than 1 in 10 children with a positive COVID test who had any symptoms at all (fever, cough, rhinorrhea, gastrointestinal symptoms) were recognized as having COVID-19 at symptom onset.

In the children who remained symptomatic throughout the study period, virus RNA was able to be detected in the upper respiratory samples for an average of 14 days. That rose to just under 17 days for all of the children.

Of course, detection of viral RNA does not correlate directly with being infectious, an important unknown at present.

Recommendations almost certainly will evolve as we get more detailed data from reopened schools, but for now the 10- to 14-day quarantine period stands as the current recommendation.

Mitigation Works

Many of us heard about the outbreak of SARS-CoV-2 among attendees of a summer camp in Georgia. However, the results from four overnight camps in Maine have received much less attention.

The camps in Maine implemented multiple layers of interventions to protect over 1000 staff members and campers. I think it's worth reviewing them just to illustrate how aggressive a mitigation program can be.

First, the attendees were asked to interact only with family members for at least 10 days before arrival at camp. All were tested 5-7 days before camp arrival, and results were negative or pending. Once at camp, everyone was quarantined with their camp cohort for 14 days whether they had symptoms or not. They all underwent repeat SARS-CoV-2 testing approximately 1 week after arrival to camp. After that, symptom screening was done for each camper and staff member daily, but testing was done only if someone developed symptoms.

Both campers and staff received extensive instruction on hygiene measures and were required to wash their hands before and after all activities, meals, and after any other "high touch" interaction. Campers and staff always wore cloth face coverings. Staff members did not leave the camp on their days off.

Other interventions included reducing or eliminating any indoor activities, staggering dining hall times or dining outdoors, and even separate bathroom use by cohort. The bathrooms were cleaned and disinfected twice a day.

The outcomes of these efforts were amazing and attest to the value of cohorting and limiting movement in and out of the cohorts. Only three individuals had a positive test after arrival to camp, identified in the repeat testing after about 1 week at camp. They were isolated and did not infect anyone else. A dozen people developed symptoms during later weeks of camp, but none of them tested positive.

Obviously, this is the kind of "premier" approach that only residential schools could consider using (because their students presumably don't go home after classes). However, this observational study emphasizes that aggressive mitigation strategies can be effective.

The pandemic has certainly been hard on children and parents alike, and the idea of limiting their child's interaction outside of school will be tough for many families to consider much less follow. However, limiting a child's interaction to the family cohort and their school cohort as much as possible may be one of the best contributions families can make to ensure a safe return to school.

William T. Basco, Jr, MD, MS, is a professor of pediatrics at the Medical University of South Carolina and director of the Division of General Pediatrics. He is an active health services researcher and has published more than 60 manuscripts in the peer-reviewed literature.

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